Discovery delighted by ruling

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Thobeka Xaba from Katlehong in Ekurhuleni needs urgent cancer treatment or she will die but Discovery is refusing to pay for the drug her encologist has prescribed, insisting on another which is likely to cause her to have a heart attack.
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Picture: Boxer Ngwenya

Johannesburg - Discovery Health Medical Scheme says it has been vindicated over the treatment of Ekurhuleni cancer patient Thobeka Xaba.

This follows a recent appeal committee of the Council for Medical Schemes (CMS) ruling in favour of Discovery.

Xaba, 23, has struggled with a form of cancer called fibromyxoid sarcoma since she was a child, and began losing mobility on her left arm last month because of the invasive cancer.

Discovery had declined to authorise Paclitaxel - the medicine prescribed by her oncologist, Dr Daleen Geldenhuys - saying it was a “tier two” medicine not covered by her plan, which covered only “tier one” medicine, among other reasons.

Paclitaxel, Geldenhuys said, had reduced the chance of her patient having heart failure and that if Xaba was treated with Doxorubicin (which was recommended by Discovery), she had up to a 40-percent chance of heart failure.

In May, advocacy organisation Campaigning for Cancer helped Xaba to lay a complaint against Discovery with the CMS.

In a letter to the CMS on May 31, Discovery said it would not pay for Xaba’s medicine because it “is not a covered benefit on her selected plan type and the treatment requested is not the level of care available in the public sector”.

Discovery maintained that there was no medical evidence that Paclitaxel was effective in treating Xaba’s condition.

In early June, the council ruled against Discovery, saying the laws governing medical schemes obliged them to substitute drugs when there was a risk of the patient being harmed “without penalising the patient”.

Two weeks later, Discovery wrote to the CMS, indicating it would appeal against the decision, and continued to refuse to pay for Paclitaxel.

In the meantime, Discovery and Geldenhuys reached an agreement during the hearing on August 8 that the scheme would provide Xaba with the treatment the oncologist had recommended. However, the ruling, dated August 15, eventually sided with Discovery.

The committee stated that an independent cancer specialist, who had been contacted by Discovery, confirmed that Paclitaxel was the inappropriate drug to treat a soft-tissue sarcoma.

The ruling goes on further to state that during deliberations, Geldenhuys conceded there was not enough data available to support the use of Paclitaxel to treat soft-tissue sarcoma.

In response to the ruling, Discovery Health chief executive Dr Jonathan Broomberg said Geldenhuys had misled the press, as well as Campaigning for Cancer and the public, in “a single-minded quest to have an urgent hearing”, in order to force Discovery to fund treatment with Paclitaxel while not an appropriate treatment for the condition.

He added that she misled the public, Discovery, the media and the CMS, saying Xaba had had no treatment since March 25, and that as a result Xaba’s health was swiftly deteriorating.

“At the hearing, Dr Geldenhuys admitted that Ms Xaba had in fact had three cycles of Paclitaxel funded by the doctor herself, and that her health was apparently markedly improving as a result. Discovery’s insistence that the appropriate treatment be provided, even at a much higher cost, was ultimately vindicated as the appropriate approach, contrary to what has been reported in the press,” Broomberg said.

Geldenhuys said she strongly denied having misled anybody regarding the seriousness of Xaba’s condition and the urgency to get a hearing with the CMS, which was initially scheduled for September 20, three-and-a-half months after the patient had escalated her complaint to the CMS.

“I am relieved that tier 2 medication was approved for her which previously was denied prior to the appeal hearing,” Geldenhuys said.